Basic Information
| Provider Information | |||||||||
| NPI: | 1326056003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUCHA | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675851918 | ||||||||
| FaxNumber: | 4198247359 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 KIMOLE LN | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492211478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172639491 | ||||||||
| FaxNumber: | 5172639591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4301088792 | MI | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 156940 | 01 | MI | GLHP | OTHER | 06316 | 01 | PARAMOUNT | OTHER | 000000493280 | 01 | MI | ANTHEM | OTHER | 4928260 | 05 | MI | MEDICAID | P00357849 | 01 | MI | RRMC | OTHER | 7819885 | 01 | AETNA | OTHER | 0404610882 | 01 | MI | BCBS MI | OTHER | 144133 | 01 | MI | CARE CHOICE PREFERRED C | OTHER | 40042 | 01 | HPM | OTHER | 4907804 | 05 | MI | MEDICAID |